SUPERVISOR HIGH RISK SOCIAL WORK

Summary

• Collaborates with the interdisciplinary team of healthcare professionals involved in the plan of care for high-risk patients including, but not limited to, hospital-based Case Management and clinical staff, the patient's primary provider, RN Care Coordinator, practice team members and community partners.
• High visibility with community partners in the forms of education, liaison and assisting with the management of care across the healthcare continuum.
• Supports initiatives with long stay patients, readmissions, disease processes and patient experience.
• Collaborates with all areas of Care Coordination including inpatient, outpatient, emergency room, ambulatory care, community partners and transitions to achieve the best possible patient outcomes.
• Works in partnership with Supervisor of Inpatient Case Management, Supervisor of Care Transitions, Manager of Care Coordination and Director of Care Coordination for positive outcomes
• Enhances the delivery of patient care services across the continuum by helping to empower patients and their support system(s) to better understand their health goals and to manage their health needs.
• Provides supervision to the social work team as well as direct social work intervention and consultation upon request/referral from patients, families, healthcare professionals, and other community members

Essential Duties and Responsibilities

• Supports and promotes the mission and values of Covenant Health Ministry.
• Provides and/or oversees the provision of appropriate and timely resources, interventions, and services for selected patients in the hospital and IMG practices.
• Provides supervision of all social work staff in the Department and graduate students in fieldwork placement at SJH.
• Provides clinical supervision to professional staff and consultation regarding cases presenting difficult issues as needed.
• Completes performance evaluations and stay interviews within determined timeframes
• Participates in initiatives to promote clinical and professional collaboration within the hospital, Integrated Management Group, system-wide and in the community.
• Works collaboratively with the Director and other members of the Care Coordination team to provide a seamless transition across the continuum of care.
• Assists with development of policies, procedures, competency, and orientation documentation and acts as preceptor when needed
• Assists with disciplinary matters involving the Case Management/Care Coordination/Social Work staff in collaboration with the Director.
• Participation in leadership development opportunities.
• Plans, communicates, and collaborates with the patient and/or family, the provider, and the interdisciplinary team to develop the optimum post-hospitalization care plans
• Applies relevant CMS regulations and discharge guidelines to ensure compliance with Medicare Conditions of Participation.
• Identifies opportunities for improvement in processes and quality of care and communicates findings to the Director of the department and colleagues.
• Identifies high risk patients & families and makes referrals to Quality and Risk Management
• Actively participates in Performance Improvement.
• Collects and analyzes data that reflects process improvement activities for Care Coordination
• Maintains current knowledge of DNV & CMS regulations.
• Demonstrates a commitment to maintain competencies and participates in those activities, which contribute to the ongoing development of self, the profession, and other members of the health care team.
• Annual goals are achieved.
• Acts as a role model for other Social Workers.
• Case Management/Care Coordination/Social Work representation on hospital committees.
• Coordinates special projects as requested
• Pertinent and consistent communication with Inpatient Care Management, Outpatient Care Coordination Teams, and Community Partners
• Work in partnership with Care Coordination Team to provide patients with essential resources
• Aids Physician Practice hubs and Community Partners as needed for continuum of care
• Collaborates with Supervisor of IP Case Management, Supervisor of Care Transitions, Manager of Care Coordination and Director regarding Complex Care Patients i.e., social admissions, guardianship cases, readmissions, extended stay patients, etc.
• Ability to work with families of diverse patient populations
• Ability to advocate/negotiate for patients through systems
• Completes all mandatory learning assignments within specified timeframes
• Assists with development of initiatives to aid in SW interventions for social determinants of health, readmissions, behavioral health, and management of patient-centered care in the practices.
• Ensures that plans are focused and effective which helps patients to connect with and utilize a full range of medical, community and other services available.
• Responsible for assuring that there is sufficient social work coverage to meet the needs of patients in collaboration with the Director.
• Ensures that social work staff maintains/enhances professional development.
• Performs bio-psychosocial assessments with patients and/or family members.
• Make recommendations for direct service and/or referral for a wide range of community resources, based on assessments of patient and family needs.
• Provides direct intervention to patients and families based upon the assessment, identified need, and patient’s willingness to participate and consent.
• Assists the patient/family to understand and accept medical recommendations and supports patient/family with decision.
• Participates in staff and team conferences, discharge planning meetings, and family conferences.
• Provides information on financial resources to patients/families.
• Assists in completing applications for Medicaid and other financial assistance
• Participation in leadership development opportunities.
• Works collaboratively with the Director and other members of the Care Coordination team to provide a seamless transition across the continuum of care.
• Maintains effective working relationship with other professionals in the community.
• Serves on community committees as appropriate.
• Participates and collaborates with Director and other leaders to promote community involvement, visibility, and essential resources
• Maintains current knowledge of organization’s policies and procedures as well as community resources.
• Other duties as consistent with this role.

Job Requirements

Job Knowledge and Skills

• Experience and comfort working with adult patients >18 who have complex medical and/or psychiatric problems.
• Ability to work with families of diverse patient populations
• Strong assessment skills
• Ability to advocate/negotiate for patients through systems
• Good organizational skills
• Strong interpersonal skills enabling effective team collaboration
• Maintains confidentiality
• Knowledge of end-of-life issues
• Knowledge of community agencies and resources
• Ability to work remotely as needed

Education and Experience

• MSW from an accredited school for Social Work
• LICSW preferred
• LCSW required
• Minimum of two years’ experience in a health care setting preferred

An equivalent combination of education and experience which provides proficiency in the areas of responsibility listed above may be substituted for the above education and experience requirements.

Working Conditions/Physical Demands

Must possess the physical and mental abilities to perform the tasks normally associated with this position that involves a combination of sitting, standing, walking, bending, stooping, and reaching. Occasional lifting/carrying up to 25 lbs. Some stress related to high level of responsibility for quality care.

Americans with Disabilities Statement

Must be able to perform all essential functions of this position with reasonable accommodation if disabled.

The above statements are intended to describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified. Covenant Health reserves the right to modify position duties at any time, to reflect process improvements and business necessity.

Standard of Business Conduct

Every St Joseph Hospital employee is required to abide by the Standards of Conduct and to report any activity that appears to violate the Standards of Conduct.